Suchergebnisse

The primary aim of the research project was to develop conceptual models of rural ambulance service delivery based on different worldviews or philosophical positions, and then to compare and contrast these new and emerging models with existing organisational policy and practice. Four research aims were explored: community expectations of pre-hospital care, the existing organization of rural ambulance services, the measurement of ambulance service performance, and the comparative suitability of different pre-hospital models of service delivery. A unique feature was the use of soft systems methodology to develop the models of service delivery. It is one of the major non-traditional systems approaches to organisational research and lends itself to problem solving in the real world. The classic literature-hypothesis-experiment-results-conclusion model of research was not followed. Instead, policy and political analysis techniques were used as counter-points to the systems approach. The program of research employed a triangulation technique to adduce evidence from various sources in order to analyse ambulance services in rural Victoria. In particular, information from questionnaires, a focus group, interviews and performance data from the ambulance services themselves were used. These formed a rich dataset that provided new insight into rural ambulance services. Five service delivery models based on different worldviews were developed, each with its own characteristics, transformation processes and performance criteria. The models developed are titled: competitive; sufficing; community; expert; and practitioner. These conceptual models are presented as metaphors and in the form of holons and rich pictures, and then transformed into patient pathways for operational implementation. All five conceptual models meet the criteria for systemic desirability and were assessed for their political and cultural feasibility in a range of different rural communities. They provide a solid foundation for future discourse, debate and ...

The main objective of this epidemiological study was to assess the incidence of unintentional non-fatal injuries, together with their determinants and consequences, in a defined Vietnamese population, thus providing a basis for future prevention. A one-year follow-up survey involved four quarterly cross-sectional household injury interviews during 2000. This cohort study was based within a demographic surveillance site in Bavi district, northern Vietnam, which provides detailed, longitudinal information in a continuous and systematic way. Findings relate to three phases of the injury process: before, during and after injury. The study showed that unintentional non-fatal injuries were an important health problem in rural Vietnam. The high incidence rate of 89/1000 pyar reflected almost one tenth of the population being injured every year. Home injuries were found to be most common, often due to a lack of proper kitchens and dangerous surroundings in the home. Road traffic injuries were less common but tended to be more severe, with longer periods of disability and higher unit costs compared with other types of injury. The leading mechanisms of injury were impacts with other objects, falls, cuts and crushing. Males had higher injury incidence rates than females except among the elderly. Elderly females were often injured due to falls in the home. Being male or elderly were significant risk factors for injury. Poverty was a risk factor for injuries in general and specifically for home and work related injuries, but not for road traffic injuries. The middle income group was at higher risk of traffic injuries, possibly due to their greater mobility. Injuries not only affected people's health, but were also a great financial burden. The cost of an injury, on average, corresponded to approximately 1.3 months of earned income, increasing to 7 months for a severe injury. Ninety percent of the economic burden of injury fell on households, only 8% on government and 2% on health insurance agencies. Self-treatment was the most common way of treating injuries (51.7%), even in some cases of severe injury. There was a low rate of use of public health services (23.2%) among injury patients, similar to private healthcare (22.4%). High cost, long distances, residence in mountains, being female and coming from ethnic minorities were barriers for seeking health services. People with health insurance sought care more, but the coverage of health insurance was very low. Some prevention strategies might include education and raising awareness about the possible dangers of injury and the importance of seeking appropriate care following injury. To avoid household hazards, several strategies could be used: better light in the evening, making gravel paths around the house, clearing moss to avoid slipping, wearing protective clothing when using electrical equipment and improving kitchens. Similarly, improving road surfaces, having separate paths for pedestrians and cyclists and better driver training could reduce road accidents. In Vietnam, and especially in a rural district without any injury register system, a community-based survey of unintentional injuries has been shown to be a feasible approach to injury assessment. It gave more complete results than could have been obtained from facility-based studies and led to the definition of possible prevention strategies.

PROBLEM ADDRESSED: Recruitment and retention of physicians appropriately trained for rural practice in Canada continues to be a serious challenge. We describe three integrated educational programs at the University of Alberta that aim to increase students' and residents' participation in rural health care and encourage them to take up practice in rural areas. OBJECTIVES OF PROGRAM: To expand and enrich rural educational experiences at undergraduate and postgraduate levels and to supplement family medicine postgraduate education with a third-year special-skills program for rural practice. MAIN COMPONENTS OF PROGRAM: Main components are sustained, reliable funding from the Government of Alberta for the Rural Physician Action Plan; adequate infrastructure to support the program; and commitment by university faculty, rural physicians, and communities. CONCLUSION: The rural-based educational programs have allowed more than 95% of medical students to gain experience in rural areas. The number of family medicine residents doing rural rotations has doubled, and the length of experiences in rural practice has increased fourfold. The third-year special-skills training for rural practice has expanded greatly, and at least 26 of 49 participants have gone on to enter rural practice. In more than 30 rural Alberta communities, 56 physicians have had an important influence on the training of medical students and family medicine residents.

This paper describes the development and characteristics of a comprehensive, integrated and sustained program for the education, recruitment and retention of physicians for rural practice in Alberta--the Rural Physician Action Plan. The participation of key stakeholders (including government, the provincial medical association, the licensing authority, faculties of medicine, practising rural physicians and regional health authorities) and a sustained program budget have been key organizational issues for success. Critical to the effectiveness of this program has been the focus on professional and lifestyle issues targeting 3 distinct groups: physicians in training, physicians in practice, and rural communities and health authorities. Substantial program funding since 1991-92 of up to $3 million per year has increased rural-based activities significantly. For example, 87% of medical students and 91% of residents in family medicine in Alberta now experience 4 weeks or more of rural practice. The authors believe that the historic issues and recent trends militating against recruitment and retention of rural physicians will continue unchecked without comprehensive and sustained approaches such as Alberta's Rural Physician Action Plan.

This study was designed to investigate the influence of cultural and economic factors on health seeking behaviour. Fieldwork was conducted in Funyula Division in Busia District, Western Kenya between December 1997 and February 1998. The study sought to find out those factors that are significantly related to orientation towards health seeking for various ailments in a two-way medical delivery system (i.e modem and traditional African medicine). Thus the effects of occupation, formal education level and beliefs on the causation and etiology of particular disease in the area were sought.The study was based on a sample of 60 households and 12 key informants. The methods used in obtaining data information for this study were survey interviews based on a questionnaire, library reading and in depth studies with key informants. The data were analyzed both quantitatively and information presented in the form of tables and cross-tabulations, and qualitatively in which direct quotations and local taxonomies were used.The findings reveal that since health has multiple determinants there may be various pathways through which a household could maintain the same level of health; that is to say, households find different mechanisms for adapting to the same circumstances where some are more successful than the others. However,the mechanism to be chosen is contingent upon the perception and the etiology of the disease. The disease etiologies are put into two broad categories, namely natural and supernatural which in turn influence therapy seeking and selection behaviour.The selection of a therapeutic system does not always follow cause and effect model rather the domain of these two resort systems overlap. When the first model from the etiological concept fails to provide satisfactory results, another one is tried. People do not actually stick to the distinction but move freely from one medical system to the other even on the same type of illness. Health seeking behaviour of the Abasamia in Funyula Division is affected by a number of factors. Occupation and actual beliefs of the people were found to extend a lot of influence on peoples health seeking behaviour while educational level had no significant influence on therapy seeking.It is, therefore, recommended that since traditional medicine is being used widely for various types of ailments in rural areas and even in some parts of urban settlements, the government of Kenya should recognise traditional healers by way of legislation and to set out to develop their potential and the creation of an enabling environment for them to practice medicine, as it is clear from the findings of this study that they remain a major source of health care for many of the rural dwellers.

We have the technology. What is needed is government financial commitment, so argues Kristen Jakobsen in the following discussion of "telemedicine." The term refers to the delivery of health care services by means of modern telecommunications technology. According to Ms. Jakobsen, the telephone, the fax machine, the Internet, and interactive audio-visual transmissions hold the key to making medical care more accessible and less expensive. Potential beneficiaries include vast populations of elderly in rural areas, who tend to be remote from upscale health care facilities and in need of the wherewithal to reach them. Standing in the way, in Ms. Jakobsen's view, is a government which lacks the boldness and the vision to lay an adequate fiscal foundation for this promising possibility.

Bibliographical references. ; With the advent of the new government and the end of the apartheid era, the Department of Welfare investigated methods whereby the demand for equitable access to state subsidised homes for the aged might be met. It was decided to develop an instrument to assess dependency needs of older persons that might warrant admission to homes for the aged. Financial constraints dictated that only 2% of those over the age of 65 years could be institutionalised in state subsidised homes. An instrument with high specificity and sensitivity and good face and construct validity was required in order not to exclude the needy or include the undeserving in subsidised institutional care. The instrument formerly used in South Africa was designed to assess dependency needs of urban-living individuals and assumed relative affluence in contrast to the reality of the situation of the bulk of the South African population. The instrument was deficient in that it assessed only mental and physical disabilities. It did not take into account the wide disparities relating to primary needs (such as water, food, sanitation and security) that exist among communities with widely disparate socio-economic status. Since South Africa is a developing country, a significant component of the elderly population live in extreme poverty, often in rural subsistence-economy conditions. Instruments used in other countries, which assume a certain level affluence, are thus not applicable to the majority of the South African population.

The population of Assam is 26.64 million (2001), more than 85% of which live in rural areas. The state is one of the poorer states in the country, with an estimated GDP per capita equal to Rs. 12,163, which is less than two thirds of the national average (2001-02). Growth in the 1980-90s has been one of the lowest in the country (just above 1 percent real per capita growth), although the economic situation is reported to have improved in more recent years. The economy is predominantly rural (40 percent of Net State Domestic Product is from agriculture, and 74 percent of the population is engaged in agriculture), and it is heavily dependent on the tea estate sector (800 tea gardens that produce 15% of the world tea). The non-agricultural principal activity is oil and gas extraction and transformation (there are two oil refineries in the North-Eastern part of the state, plus a third one is under construction). Population below poverty line is estimated to be 36 percent, scheduled caste 7.4 percent and scheduled tribe 12.8 percent of the total population.

In 1995, the National Library of Medicine (NLM) and the Public Health Service (PHS) recommended that special attention be given to the information needs of unaffiliated public health professionals. In response, the National Network of Libraries of Medicine (NN/LM) Greater Midwest Region initiated a collaborative outreach program for public health professionals working in rural east and central Iowa. Five public health agencies were provided equipment, training, and support for accessing the Internet. Key factors in the success of this project were: (1) the role of collaborating agencies in the implementation and ongoing success of information access outreach projects; (2) knowledge of the socio-cultural factors that influence the information-seeking habits of project participants (public health professionals); and (3) management of changing or varying technological infrastructures. Working with their funding, personnel from federal, state, and local governments enhanced the information-seeking skills of public health professionals in rural eastern and central Iowa communities.

FOOD HABITS, DIETARY INTAKE AND NUTRITIONAL STATUS DURING ECONOMIC CRISIS AMONG PREGNANT WOMEN IN CENTRAL JAVA, INDONESIA Th. Ninuk Sri Hartini, Epidemiology and Public Health Sciences, Dept. of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden; Community Health and Nutrition Research Laboratories, Gadjah Mada University, Jogjakarta, Indonesia; Nutrition Academy, Ministry of Health, Jogjakarta, Indonesia ABSTRACT Objectives: The overall objective of this thesis was to study the effect of the economic crisis on food habits, dietary intake and nutritional status among pregnant women in Purworejo District, Central Java, Indonesia. Subjects and methods: Since 1994, the Community Health and Nutrition Research Laboratories (CHN-RL), Gadjah Mada University, Jogjakarta, Indonesia have operated a surveillance system in Purworejo District, Central Java, Indonesia. Between 1996 and 1998, a monthly monitoring of new pregnancies took place within the surveillance system. This project included a detailed evaluation of dietary intake during pregnancy. Each trimester six repeated 24-hour recalls were conducted on 450 pregnant women. Weight and mid-upper arm circumference (MUAC) were measured monthly, height and serum ferritin concentration was measured once. Here, the dietary intake and nutritional status of the women during the second trimester are evaluated in relation to the emergence of the economic crisis, that started in 1997. Women were classified into four socio-economic groups. A computer program (Inafood) was developed to calculate nutrient intake. To support the quantitative results, a qualitative study was carried out between January and June 1999. Focus group discussions were held with four groups of women, in-depth interviews with 16 women, three traditional birth attendants and four midwives, and observations were carried out with four women. Here, food habits and coping strategies in relation to the economic crisis were explored. Results: Before the crisis, more than 80% of the pregnant women had inadequate energy and 40% had inadequate protein and vitamin A intake. All women had inadequate calcium and iron intake. The food intake consisted of rice, nuts and pulses and vegetables, meaning that it was mainly plant-based food. Rice behaved as a strongly inferior good in economic term, meaning that its consumption increased in spite of its price increase. Rice remained an important supplier of energy, protein and carbohydrates also during the crisis. Especially, rural, poor women with access to rice fields increased their rice intake and decreased their intake of non-rice staple foods. Reasons for the continued rice intake included the women had been accustomed to eating rice since they were born and that cooking methods for non-rice staple foods were difficult. The intake of animal food was low initially and decreased further during the economic crisis. Rich women decreased their intake of fat. The intake of nuts and pulses and vegetables increased for most groups. Nuts and pulses were an important supplier of calcium and iron, and vegetables were an important supplier of vitamin A. The rural, poor women with access to rice fields kept their food taboos also during the crisis. Rich women were able to maintain a good nutrient intake during the crisis, although fat intake decreased. Also, urban poor and rural, poor, landless women had an increased intake "during crisis" because relatives and neighbour provided some foods and perhaps also because of the government support programme. Conclusion: Before the crisis, energy and nutrient intake of pregnant women were inadequate. The food pattern of the women was predominately plant-based. Rich women were able to maintain a good nutrient intake during the crisis, although fat intake decreased. Rural poor women with access to rice fields had a higher rice intake than other groups throughout the crisis. Urban poor and rural poor, landless women experienced a decreased intake of most nutrients in the transition period but an increased intake during the crisis, reflecting government intervention and support from relatives and neighbours. The latter, however, is not sustainable. Thus, vulnerable groups are at risk of developing nutritional deficiencies without food support programmes. Key words: Food intake, nutrient intake, nutritional status, food pattern, pregnancy, food habits, coping strategies, economic crisis, Indonesia.

Carol Etherington, recipient of the 1999 Nobel Peace Prize, is a member of the American board of directors of Doctors Without Borders (Médecins Sans Frontières) and is a psychiatric nurse who has worked extensively with traumatized populations in community and post-disaster settings worldwide. She provides her perspective on issues and concerns surrounding the need to provide humanitarian emergency medical assistance to populations, especially children, in danger around the world. The acting president of DWB, an international humanitarian aid organization that provides emergency medical assistance to populations in danger in more than 80 countries, Etherington is an assistant professor of community health at the Vanderbilt University School of Nursing in Nashville and also a board member of DWB. As a clinical nurse, mental health trauma specialist and disaster response team member, Etherington has worked in multiple settings, from the rural areas of Appalachia to Cambodia and from the city streets of Nashville to Sarajevo. An advocate and voice for vulnerable and victimized populations, Etherington has designed, implemented and administered programs that address the health and mental health needs of populations experiencing severe physical and emotional trauma. Etherington helped treat victims of a brutal regime in Cambodia and offered comprehensive mental health services to residents of Bosnia in her role with the International Medical Corps and Medicins Sans Frontieres, or Doctors Without Borders. She has also worked with local governments and international teams in Honduras, Kosovo, Poland, Tajikistan, Sierra Leone and Angola to set up community-based programs that address post-traumatic conditions in the aftermath of war and natural disaster. She has served as a volunteer in multiple national disasters, including New York City after Sept. 11. In 1986 she designed and directed Police Advocacy Support Services. For her work domestically and abroad, Etherington was one of two Americans and 36 recipients worldwide to receive the 1997-98 International Red Cross Florence Nightingale Medal.

For all of the last century, the economy of South Africa, and so also of its neighbouring countries, has depended on migrant labour from rural areas. This is particularly so for the mining industry, especially hard-rock mining, and this has led to a system of oscillating migration whereby men from rural areas come to live and work on the mines without their wives or families, but return home regularly. This pattern of oscillating migration is an important determination of health and especially at the start of the epidemic, contributed to the spread of HIV in Carletonville, the largest gold-mining complex in the world. We first consider the political and economic context within which earlier attempts to develop HIV intervention programmes were made and then show how the Carletonville project was based on a set of assumptions. First, that HIV should not be treated as another biomedical problem to be dealt with by changing individual behaviour but rather that it must be understood within the social, cultural and normative conditions that pertain in particular communities. Secondly, that in the short to medium term the most effective interventions would involve the treatment of sexually transmitted diseases and the use of community-based peer educators to promote safer sexual practices and the use of condoms. Thirdly, that for the intervention to sustainable for long term, it would require the full commitment of the local stakeholders including the state, the private sector, the trade unions and local community-based organisation. Fourthly, that in order to understand the nature and patterns of the epidemic, to focus our intervention efforts so that they have the maximum effect, to make sensible predictions as to the likely future course of the likely future course of the epidemic, and finally, to carry out detailed monitoring and evaluation of the epidemic using both biomedical and behavioural markers of infection and behaviour. The background and the current status of the project are described in detail. The surveys have shown that the situation is even worse that envisaged young women from infection. Valuable lessons have been learnt concerning the reasons for the continued spread of the epidemic and some success has been achieved especially in the empowerment of women at high risk and the mobilization of people from all sectors of the community to join the flight against HIV/AIDS. It is still too early to show significant changes in STI or HIV rates but it is hoped that this will become apparent over the course of the next one or two years.

India's achievements in the field of health have been less than satisfactory and the burden of disease among the Indian population remains high. Infant and child mortality and morbidity and maternal mortality and morbidity affect millions of children and women. Infectious diseases such as malaria and especially TB are reemerging as epidemics, and there is the growing specter of HIV/AIDS. Many of these illnesses and deaths can be prevented and/or treated cost-effectively with primary health care services provided by the public health system. An extensive primary health care infrastructure provided by the government exists in India. Yet, it is inadequate in terms of coverage of the population, especially in rural areas, and grossly underutilized because of the dismal quality of health care provided. In most public health centers which provide primary health care services, drugs and equipments are missing or in short supply, there is shortage of staff and the system is characterized by endemic absenteeism on the part of medical personnel due to lack of oversight and control. As a result most people in India, even the poor, choose expensive health care services provided by the largely unregulated private sector. Not only do the poor face the double burden of poverty and ill-health, the financial burden of ill health can push even the non-poor into poverty. On the other hand, population health is instrumental for both poverty reduction and for economic growth, two important developmental goals. India spends less than 1% of its GDP on public health, which is grossly inadequate. Public investment in health, and in particular in primary health care, needs to be much higher to achieve health targets, to reduce poverty and to raise the rate of economic growth. Moreover, the health system needs to be reformed to ensure efficient and effective delivery of good quality health services.

Every year about half a million women die from complications of pregnancy, parturition and puerperium, most of which are preventable. The purpose of this thesis was to chart the distribution and decline in maternal mortality in Sweden between 1751 and 1980, and furthermore to characterize positive (predisposing) factors and negative (protective) factors of maternal mortality. Maternal mortality declined from 900 to 6.6 per 100,000 live births in these 230 years. Maternal deaths accounted for 10070 of all female deaths in the reproductive ages between 1781 and 1785, but only 0.2.0/0 between 1976 and 1980. However, in the 19th century 40-450/0 of the female deaths in the most active childbearing ages were maternal deaths. The children left motherless had an extremely high mortality. Indirect maternal deaths and puerperal sepsis accounted for the bulk of maternal deaths in the rural areas. Only a minority of maternal deaths occurred in lying-in hospitals. Midwifery services in rural areas and antiseptic techniques were most effective in preventing maternal deaths during the late 19th century. The changing distribution ofage and parity amongst the parturients had a definite impact on the mortality decline, enhanced by time, contributing to 500/0 of the mortality decline over the last 15 years. The expontential decline of cause-specific mortality and case fatality rates during the last 40 years is furthermore explained by the emergence ofmodern medicine - antibiotics, antenatal and obstetric care. The earlier serious problem of illegal abortions was eradicated by legislation and changes in hospital practice. The maternal mortality decline has levelled out during the 1970s, the relative importance of embolism as a cause of death is increasing. Advanced age and intercurrent disease are the most difficult risk factors to overcome. To conclude, this study indicates that the reason why maternal mortality has declined faster than otherhealth indices is that the major part of the maternal deaths can be prevented by medical technology, including family planning, antenatal and obstetric care. This experience should be of interest to developing countries where high rates of maternal mortality prevails.

US medical care reflects the priorities and influence of academic health centers. This paper describes the leadership role assumed by one academic health center, the State University at Buffalo's School of Medicine and Biomedical Sciences and its eight affiliated hospitals, to serve its region by promoting shared governance in educating graduate physicians and in influencing the cost and quality of patient care. Cooperation among hospitals, health insurance payers, the business community, state government, and physicians helped establish priorities to meet community needs and reduce duplication of resources and services; to train more primary care physicians; to introduce shared governance into rural health care delivery; to develop a regional management information system; and to implement health policy. This approach, spearheaded by an academic health center without walls, may serve as a model for other academic health centers as they adapt to health care reform.